I think we can all agree that:
Finding the BEST addiction treatment program is nearly impossible.
Or is it?
As it turns out, treating addiction is MUCH more effective when all of the care is customized to each patient. It seems obvious right? The problem is that this rarely ever happens, even when addiction centers make this claim.
So how is healthcare effectively customized?
It starts with careful planning to ensure top quality care from every aspect of treatment. I will explain this in detail below.
The treatment facility and all associated medical professionals play vital roles. The location and treatment amenities must be energizing and motivating, but the quality of staff are even more important.
Let’s start with therapists. The American Psychological Association has agreed that the ability to bond or form a quality therapeutic alliance is one of the most important characteristics of a therapist. While really good therapists can achieve this bond with a vast majority of patients, there are plenty of average therapists and difficult patients that will struggle to build an effective level of rapport. This is particularly problematic within an inpatient addiction center as many facilities will not allow patients to choose their therapist. Patients are assigned a therapist, and it is often impossible to switch, despite having a poor or non-existent therapeutic alliance. This in itself can result in failed addiction treatment. Therapists also have varying levels of expertise with each psycho-therapeutic modality. Different modalities include cognitive therapy, interpersonal therapy, habit reversal therapy, etc. Outpatient addiction treatment allows patients to determine the type of therapy used and an associated therapist with expertise in that treatment area.
While a therapeutic bond is important, addiction patients also need therapists with appropriate training.
That last sentence seems self-explanatory, but it isn’t. Many addiction treatment facilities utilize licensed chemical dependency counselors (LCDC’s). Quality LCDC’s are quite effective at teaching skills that support sobriety, and they have a strong role within the addiction field. These chemical dependency counselors are very beneficial when utilized correctly, but they often aren’t. LCDC’s should work effectively with licensed professional counselors (LPC’s) in addiction settings. Quality LPC’s are not only trained in addiction but also in a broad range of therapeutic techniques to treat all mental health disorders.
The ability to provide counseling across the spectrum of mental illness is vital to comprehensive addiction treatment. The percentage of addiction patients with a serious mental illness ranges from 30-60%, depending on the research study that you read. Pay attention to the bolded word above – serious. The majority of the remaining patients without a serious mental illness experience a lower degree of symptoms or mental flaws that could benefit from counseling. Actually, it is my opinion that we could all benefit from quality counseling.
Treatment for addiction should thus include dedicated treatment with a LPC or even more experienced - PhD level therapist. Many addiction treatment centers do not include such highly trained therapists or do not have enough to support the volume of patients.
In my experience, individual counseling with a LPC should start with 2-3 sessions/week for at least 3 weeks before decreasing frequency. Patients need to build a firm foundation in therapy, so that the techniques can be practiced effectively outside of appointment times. Relapses should prompt more frequent treatment. Few inpatient centers will provide this level of care.
Effective counseling is one of the most important aspects of addiction, but medication management is also vital for those requiring medical detoxification or treatment of a serious mental illness.
Medication management is typically the realm of a physician. Any physician trained in addiction should be able to properly detox a patient and significantly reduce withdrawal symptoms. Proper detoxification does not eliminate the risk of seizures or other side effects, but it does significantly reduce the severity and likelihood of complications. Even with minimizing risks, some patients will encounter complications that may require medical hospitalization. Many patients can be safely detoxed in an outpatient setting, but certain risk factors (like past withdrawal induced seizures) may require an inpatient center for 24/7 monitoring.
Detoxification is just the start of medication management. As I mentioned earlier, 30-60% of patients with addiction have a comorbid serious mental illness. The only type of physician well trained in identifying and treating the full range of mental illness is a psychiatrist, but not all addiction physicians are psychiatrists.
Ideally, addiction patients should see an addiction physician (psychiatrist or not) for an initial evaluation to manage detoxification. Once detoxification is complete, an evaluation should be scheduled with a psychiatrist to identify and manage any mental health issues. The problem is that insurance companies will generally not pay for 2 evaluations during the same admission or with the same physician. To obtain this level of care, the patient must utilize separate physicians for detox and a later psych evaluation or pay cash. Insurance companies expect the initial detox evaluation to include all relevant mental health information. The people making these decisions at insurance companies have obviously not attempted to perform a thorough psychiatric evaluation on someone experiencing substance withdrawal. Imagine trying to obtain a detailed mental health history on someone with acute appendicitis. It can’t be done well. The same could be said for someone going through acute withdrawal and trying to accurately present a life history.
Beyond having the proper personnel in LCDC’s, LPC’s, and a psychiatrist for individual sessions, most treatment facilities include group therapy. Group therapy is led by a therapist, but peers are generally allowed to share their experiences. While some peers will provide valuable support and additional sobriety skills, others can be disruptive and insulting. I’ve seen many pleasant people leave group settings demoralized because of a peer’s behavior. The counselor leading the group should be able to quickly enforce rules and boundaries. Unfortunately, this is another area where insurance companies interfere with quality treatment. Treatment facilities may not receive reimbursement if patients are not attending groups, so counselors often provide too many chances to the offender at the detriment of the group. Another alternative would be having separate groups based on personalities, but this requires additional staff that facilities cannot afford.
Individual therapy is not interchangeable with group therapy. Insurance companies do not agree here either. Many addiction treatment centers continue to use group therapy as the main source of counseling as it is more cost-effective. This cost-cutting is to the detriment of the patient. Individual counseling is a necessity to identify personal maladaptive behaviors, treat co-morbid conditions, and encourage individual growth. Sadly, many treatment centers provide less than 1 individual therapy session/week. Infrequent therapy is ineffective therapy.
Counseling and medication management are major aspects of addiction treatment, but there are other smaller considerations that can contribute to effective care.
The environment and facility amenities significantly contribute to effective addiction treatment through elevating morale and maintaining motivation. Between physician appointments, group therapy sessions, individual therapy, and other treatment modalities, there is a lot of concentration and personal growth packed into each day. Over the course of 30-90 days, you can imagine how difficult it must be to continually stay motivated and focused. This is less of a problem with outpatient addiction treatment as patients can maintain their hobbies and activities. At inpatient centers, there should be enough fun activities, amenities, and exercise equipment to re-energize and relax from the intensity of each day. Few provide many amenities, and the result is irritable patients that provide minimal effort. Without sustained effort, treatment is unlikely to be effective.
Now that we have discussed the necessary ingredients of treatment, let’s emphasize the positive and negative attributes of outpatient, partial hospitalization, and inpatient treatment programs.
Inpatient treatment centers are the most intensive forms of treatment that were originally designed for high risk patients. They provide 24/7 monitoring, and the patient will live in the facility for an agreed upon time. People that have had complicated withdrawals in the past (like seizures) should only detox in an inpatient center. Inpatient centers often accept patients from all across the country and help to arrange flights. Removing the addicted patient from his or her home environment should prevent easy relapses from known sources of substances. It also makes it more difficult to abruptly leave treatment as family and friends are not nearby to interfere with treatment. Patients that attempt to leave early with be met with internal interventions. This level of care is also the easiest to set-up as the patient can only receive whatever treatment is available at the facility.
The downsides of inpatient treatment begin with the inability to make major alterations in the care plan. Each admitted patient replaces a discharged patient and similar treatments continue for better or worse. Inpatient centers are big money that include living arrangements, food, and an abundance of staff. To keep the facility relatively full, inpatient centers often utilize sales staff. The sales team may be staffing many addiction centers, and they are unlikely to have actually seen more than one of them. They often make mistakes or just lie regarding amenities, facility rules, and staff at each addiction center. Sales staff are not generally held accountable for these errors. According to a director I met, addiction centers have performed internal studies to evaluate whether patients will leave due to facilities failing to meet expectations. The findings showed that most newly admitted patients have already rearranged their life to accommodate treatment and will not leave due to treatment/amenity disappointments. This makes sense as the patient and their families spend a lot of time with interventions, coordinating with insurance companies, researching treatment centers, planning time away from work, finding child care, etc. After extensive planning that includes many family and friends, few new patients will be able to convince their loved ones that it is in their best interest to leave and start the planning process again. I have personally listened to patients that ask about the location of the pool, weight room, and job resource center that were promised, only to disappoint them by breaking the news.
Partial hospitalization or intensive outpatient programs are hybrid care programs that include the many resources of an inpatient treatment center but without the higher level of monitoring. Some provide housing and meals. None provide 24/7 monitoring by medical staff. Many will accept patients straight into this level of care and others will require all patients to complete their inpatient program first. Programs can vary significantly in how much care they provide and expected hours. Some will provide detoxification services and others will not. The similarities and differences between different partial hospitalization and intensive outpatient programs is so variable that it is hard to provide accurate, generalized positives and negatives.
Outpatient addiction treatment is certainly the most flexible and customizable. Interested patients can choose their psychiatrist and counselors from the community. Treatment providers can be abruptly changed if not fulfilling the needs of the patient. Care can become more or less frequent based upon progress. The detoxification process can be extended to allow a more comfortable withdrawal process. Patients can continue to live at home. They can continue or re-enter their career as soon as possible. Permanent resources can be established nearby to ensure continued abstinence. Family or marriage counseling can be added to help rebuild relationships and provide healing to affected loved ones. Local group therapies can be continued long-term.
The problems with outpatient care is that it requires more planning and engagement. Many outpatient psychiatry clinics do not have immediate availability or lack counselors to coordinate care. This may require personally coordinating a treatment program between a couple mental health clinics. An experienced primary care physician with availability may be needed to handle the initial detoxification. Unmotivated patients may quit treatment abruptly whereas a distant inpatient center would perform their own interventions. Relapsing with known nearby dealers is possible.
Regardless of the type of addiction treatment initially chosen, the goal should be effective integration into society. This may include new living arrangements with family or friends. When no other option is available, some patients will live in sober communities or halfway houses.
Even when customizing treatment, patient motivation and desire is the most important aspect of treatment. The best resources in the world can be provided, but relapse is guaranteed when the patient is apathetic or refuses to be present in treatment. For those waffling with the idea of abstinence, engaging with a therapist exceptionally trained in a therapeutic technique called motivational interviewing may be the impetus to the start of a sober/clean life.
Let me know if there are any other recommendations that should be added to keep this article current. A future post will specifically discuss pharmacotherapy as it relates to addiction.
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